4 C’s Approach to Meaningful and Lasting Positive Behavior Change

Abstract

Making intentional and sustainable positive behavior changes is difficult for most individuals. Knowledge and even expert coaching have shown meager results in guiding individuals towards a healthier diet and lifestyle. It is clear from the current research that additional approaches, which can help stem the tide of obesity and other chronic diseases, are needed. This article introduces a systematic process-based approach which focuses on the 4C’s, Clarity, Commitment, Compassion, and Consistency. It is essential for individuals to have Clarity before they begin their health journey. Clarity must address, what do I want to change, why, and how am I going to make the change. Commitment highlights the importance of following a process-based approach that focuses on small incremental changes which over time can lead to remarkable results. Compassion is the necessary ingredient which allows individuals to continue the journey despite setbacks. By staying committed to the process, by practicing self-compassion, and by finding a healthy community, the individual is slowly able to achieve Consistency in achieving and then maintaining a healthier diet and lifestyle.

“A shower or bath can be a part of a wind-down routine along with or in place of gentle stretching/yoga practice.”

The awareness of Lifestyle Medicine has grown tremendously in the last decade. ¹ The power of diet and lifestyle for good health and longevity is spreading from academic journals to everyday magazines and other forms of popular media. Many individuals have heard of the benefits of a plant-based diet for weight loss and management of other chronic diseases. As the rising tide of obesity indicates, knowledge alone is seldom sufficient to move most individuals towards a healthier diet and lifestyle.

Even employing approaches such as SMART goals, providing accountability, and regular coaching are often inadequate in propelling many individuals towards positive behavior change. Working exclusively as a Lifestyle Medicine physician has convinced me that to achieve lasting behavior change, for most individuals, an innovative and comprehensive approach is essential. The 4C’s approach, summarized in Figure 1, is one such approach. It utilizes techniques from behavioral psychology, habit science, and adds research-based tools from the fields of self-compassion and mindfulness.

Figure 1.

4C’s approach to lasting positive behavior change.

Clarity

Though the roadmap to lasting positive change will look different for different individuals, the crucial first step for anyone on this journey is Clarity. Only after it is clear to the individual that their current approach is not working, he can start to investigate what to change. At this juncture, guidance from a physician or health coach trained in Lifestyle Medicine can provide valuable insight on the what and how of change.

However, before starting this process though, Stephen Porges reminds us that in a new interaction what the individual needs most is a sense of safety. ² Creating a safe, open, and non-judgmental space is critical. When the individual feels safe, she can then share her challenges, her perspective and also share her “why.”

Early in the process, a frequent obstacle for many individuals is the belief system that they are incapable of change. Oftentimes they have tried and failed at many other diets and programs. Using Carol Dwek’s terminology, they have a fixed mindset. ³ Nearly always, these individuals may have a fixed mindset in this domain but are more flexible and highly successful in other spheres of their lives. Reminding them of the strengths and tools they already possess can be very empowering and frequently nudge them to start their health journey in earnest.

Commitment

Achieving clarity and defining health goals is a crucial step on the journey to lasting positive change. The next step in the process is Commitment. I ask my patients to now shift their attention from the end goal(s) or the finish line to the starting line. Once clarity is achieved, I find Dr Bernard Roth’s axiom of being biased towards action very useful. He frequently reminds individuals to “just get started.” ⁴

Oftentimes my patients want to make a big change or want to make multiple changes all at the same time. I gently remind them that this is a process and they do not need to reverse their diabetes or lose 50 pounds in 2 weeks or even 2 months. A healthier and ultimately a more successful approach is to focus on making small changes that can be sustained over time.

Focusing on Habits

Dr Hugh Byrne advocates a habit swap as a good way to cultivate healthier habits. ⁵ Habit swaps can work as follows: If someone likes to eat something sweet after dinner, eating strawberries with plant-based yogurt could be an alternative to strawberry ice cream. A technique that James Clear recommends is making the habit change so small that it is difficult to fail. ⁶

The approach that numerous psychologists suggest is to change the external environment in such a way that it is easier to choose the healthier option. If there are cupcakes and cheese in a person’s fridge, then this will undoubtedly be their default snack. However, having apples on the counter and grapes and strawberries in the fridge will yield a much different result.

Another useful technique is habit stacking. ⁶ After brushing their teeth, perhaps the individual can sit on their yoga mat or chair and do some stretches or deep belly breaths. This habit can be an effective tool for lowering stress and improving sleep quality. ⁷ If the chair and the yoga mat are strategically placed in the environment, this visual cue can serve as an additional reminder.

Choosing small habits, easy to do habits, swapping habits, and stacking habits are all useful ways to incorporate healthful behaviors. Taking control of the immediate environment in our homes is a crucial step in solidifying the new habits. However, these interventions alone are seldom enough to cultivate sustainable positive behavior change. You can remove the donuts and cookies from your home but you will not be able to remove them from your workplace, friend’s homes, nor escape the constant din of food-related advertising.

Internal Environment

To be able to choose an apple over a cookie, to go to a park rather than a bar, to choose overnight oats over a donut, early in the journey, is no small feat. For majority of my patients, choosing the healthier alternative requires an internal shift. Changing the internal environment is not easy but for long term positive change, it is a necessary step. Mindfulness can be an indispensable tool in achieving this internal shift.

Mindfulness

The first step is to just pause. The next step, bring focus inward, become aware of the internal state, pay attention to the bodily sensations, feelings and thoughts, and just observe. And, if we can do this on a moment by moment basis, the contemplative traditions would describe this activity as practicing mindfulness. An attitude of being open and curious to the current internal state (not denying or repressing what you are feeling, or worse, wanting immediately to change the internal state because you feel overwhelmed) can allow for a more skillful response.

Choosing an Apple Over a Cookie

Mindfulness holds the promise that over time we will choose an apple over a cookie. Most of us know from personal experience that the cookie will improve our internal state temporarily, and even though we want to choose the apple, more often than not, we choose the cookie. In order to change this internal calculus where the individual chooses an apple more often, we need a way to boost the individual's internal state when they eat the apple.

To accomplish this, the first step is to pay attention to the present moment and not eat when distracted. As individuals start incorporating healthier foods into their diet, if they pay attention, they will start to notice, the foods that they once thought were amazing are still delicious but no longer amazing. Another way to boost the internal state is to congratulate oneself every time our behavior is more in line with our goals and values. By repeatedly exposing our taste buds to whole plant foods and by embodying the good feeling we get when we make a healthier choice, slowly, over time eating an apple can be as pleasurable as eating a cookie.

Deeper Understanding

Layered on top of the societal challenges mentioned above are our own physiological challenges. As Dr. Lisle and Dr. Goldhamer illustrate in their book, The Pleasure Trap, our brain, our physiology craves calorie dense foods. Since the human race evolved in an environment of scarcity, calorie dense foods carried a survival advantage. Hence, it is not surprising that human beings get more pleasure (greater release of dopamine) from foods that have more calories. ⁸

I frequently congratulate my patients on choosing this approach. I remind them of the toxic food culture that surrounds us, and I praise them for choosing to cultivate a healthier diet and lifestyle rather than searching for the next hack, pill or procedure to address their health goals. As Dr Gabor Mate explains in depth in his new book, “The Myth of Normal,” our diet, our ways of relating to the world are neither healthy nor natural. Our sedentary lifestyle, constant demands and distractions in our day, pervasive feelings of isolation, easy access to addictive foods, and other addictive substances is neither “natural nor healthy.” ⁹

Compassion

From this deeper understanding and a more expansive perspective, my patients are able to see their struggles in a new light. They are more open to an approach that focuses on the process, on small habit change, on mindfulness, and on compassion. Dr Kristin Neff, leading researcher on self-compassion underscores the importance of self-compassion as it relates to behavior change.

First step in practicing self-compassion is seeing things clearly. Not denying that you ate a donut when you intended to eat oatmeal, but also not being overwhelmed by guilt or shame. Next step is to remain kind to oneself and not use harsh or self-denigrating language. Secondly, cultivating the attitude that I am fallible like every other human on this planet. ¹⁰ When we criticize ourselves, our stress response is triggered and this invariably degrades our internal state. Extensive research has shown a negative internal state is not conducive to the development of a new positive behavior. ¹¹

Consistency

To gain consistency in choosing the healthier option and acting more often in alignment with our true values and goals, finding healthy communities, and cultivating healthy routines can be very useful. An example of such a routine could be to consciously disengage from your cell phone and TV, and instead, foster the habit of reading or journaling. A shower or bath can be a part of a wind-down routine along with or in place of gentle stretching/yoga practice. Doing breathing exercises, meditation, or a gratitude practice are additional ways to bring the day to a gentle and intentional close. Any combination of these restorative practices will allow the individual to better manage their stress and improve their sleep.

Community

Given the normalization of unhealthy foods, it is imperative to join a community that advocates for a whole foods plant-predominant diet. Monthly plant-based potlucks, cooking classes, community walking programs such as Walk with a Doc ¹² and bimonthly group support sessions have propelled many of my patients towards a healthier diet and lifestyle. When patients learn that others are not doing it perfectly, it can allow them to relax and continue the journey. Additionally, when they see other individuals with challenges but also their resolve to stay committed, they feel inspired and want to do the same.

Identity Change

Numerous psychologists agree that lasting behavior change is ultimately a change in our identity. James Clear very simply states, “true behavior change is identity change. You might start a habit because of motivation, but the only reason you stick with one is that it becomes part of your identity.” ⁶ If you identify yourself as a runner, then this is something you do and going for a run when it’s too cold or too hot is not an imposition, it is just something you do because of who you are.

To get to this place of identity change is a process for most individuals. It is a process that requires Clarity, Commitment, Compassion, and Consistency—ultimately just sticking with it until the identity change is forged from the inside.

Lasting Positive Change

The 4C’s approach is not meant as a rigid algorithm where the health coach or the physician follows one step after another. Rather it is meant to serve as a guide and highlight the importance of viewing positive change as a process rather than an insurmountable obstacle.

Finally, the invitation for the physician or health coach is to choose the tool or technique they find useful in this article and incorporate it into their own life. By doing so, you will experience personal benefit and be able to better empathize with your patients and clients when they confront similar obstacles and challenges on their journey. This experience will no doubt make you a more effective guide. Best of all, you will then have a front row seat when ordinary individuals make remarkable transformations before your very eyes.